D R . R O D N E Y M A R T I N E Z
INTRODUCTION TO PSYCHIATRY
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ASSESMENT OF THE MENTAL STATUS
INTRODUCTION
• The mental status examination in the USA or mental state examination in the rest of the world, abbreviated MSE, is an important part of the clinical assessment process in psychiatric practice.
• It is a structured way of observing and describing a patient's current state of mind, under the domains of
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• Appearance,
• Attitude,
• Behavior,
• Mood and affect,
• Speech,
• Thought process,
• Thought content,
• Perception,
• Cognition,
• Insight and
• Judgment
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APPEARENCE
• Clinicians assess the physical aspects such as the appearance of a patient, including apparent • age, • height, • weight, • and manner of dress and
grooming.
• Colorful or bizarre clothing might suggest mania, while unkempt, dirty clothes might suggest schizophrenia ordepression
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ATTITUDE
• Attitude, also known as rapport
refers to the patient's approach to the interview process and the interaction with the examiner.
• The patient's attitude may be described for example as • cooperative,
• uncooperative,
• hostile,
• guarded,
• suspicious or
• regressed.
• The most subjective element of the mental status examination,
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BEHAVIOR
• Abnormalities of behavior, also called abnormalities of activity,include observations of specific abnormal movements, as well as more general observations of the patient's level of activity and arousal, and observations of the patient's eye contact and gait.
• Abnormal movements • Tremor or dystonia
• Tics in
• Catatonia
• Stereotypes
• Mannerisms
• Psychomotor agitation
• Akathisia
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MOOD AND AFFECT
• Mood is described using the patient's own words, and can also be described in summary terms such as • neutral,
• euthymic,
• dysphoric,
• euphoric,
• angry,
• anxious or
• apathetic
• Affect is described by labelling the apparent emotion conveyed by the person's nonverbal behavior (anxious, sad etc.), and also by using the parameters of appropriateness, intensity, range, reactivity and mobility
• They can be congruent or incongruent
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SPEECH
• This heading is concerned with the production of speech rather than the content of speech, which is addressed under thought form and thought content
• Paralinguistic features such as the • loudness,
• rhythm,
• prosody,
• intonation,
• pitch,
• phonation,
• articulation,
• quantity,
• rate,
• spontaneity and
• latency of speech.
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THOUGHT PROCESS
• Refers to the
quantity, tempo
(rate of flow) and
form (or logical
coherence) of
thought.
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THOUGHT CONTENT
• A description of thought content would describe a patient's delusions, overvalued ideas, obsessions, phobias and preoccupations.
• Abnormalities of thought content are established by exploring individual's thoughts in an open-ended conversational manner with regard to their • intensity,
• salience,
• the emotions associated with the thoughts,
• the extent to which the thoughts are experienced as one's own and under one's control,
• and the degree of belief or conviction associated with the thoughts.
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PERCEPTIONS
• A perception in this context is any sensory experience, and the three broad types of perceptual disturbance are hallucinations, and illusions.
• A hallucination is defined as a sensory perception in the absence of any external stimulus, and is experienced in external or objective space (i.e. experienced by the subject as real).
• An illusion is defined as a false sensory perception in the presence of an external stimulus, in other words a distortion of a sensory experience, and may be recognized as such by the subject
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HALLUCINATION AND
ILLUSION
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COGNITION
• Covers the patient's level of • alertness,
• orientation,
• attention,
• memory,
• visuospatial functioning,
• language
• functions and
• executive functions
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INSIGHT
• The person's understanding of his or her mental illness is evaluated by exploring his or her explanatory account of the problem, and understanding of the treatment options.
• In this context, insight can be said to have three components: • recognition that one has a
mental illness, • compliance with treatment, • and the ability to re-label
unusual mental events (such as delusions and hallucinations) as pathological
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JUDGMENT
• Judgment refers to the patient's capacity to make
sound, reasoned and responsible decisions.
• inquire about how the patient has responded or
would respond to real-life challenges and
contingencies.
• Assessment would take into account the
individual's executive system capacity in terms of
• impulsiveness,
• social cognition,
• self-awareness and planning ability.
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PSYCHIATRIC CONDITIONS
WHAT IS ABNORMAL BEHAVIOR?
Behavior that is:
Statistically unusual
Considered strange or undesirable by most people
A source of unhappiness
There are biological, psychological (personal standards), & socio-cultural factors involved in defining abnormal behavior.
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WHAT IS NORMAL BEHAVIOR?
Normality is Often Confused with Reality. Reality is That Which is Perceived by the Senses. Normal Behavior Agrees with or Conforms to the Society’s Accepted Patterns of Customs, Rules, Laws, Fears, and Taboos.
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MODERN MODELS OF ABNORMAL
BEHAVIOR
The Psychoanalytic Model Abnormal behaviors are the result of unconscious
conflicts. The Biological Model
All abnormal behaviors have a biological or physiological basis. The Cognitive-Behavioral Model
Abnormal behaviors are the result of learning maladaptive behaviors. The Diathesis-Stress Model.
Abnormal behavior is a biological predisposition & the disorder is seen under stress. The Systems Approach Model
Abnormal behaviors are produced from life-style stressors & expectations combined with biological predispositions.
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CLASSIFYING ABNORMAL BEHAVIORS
DSM-IV-TR
Handbook of disorders used by therapists.
It provides descriptions, not causes or treatments.
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THE MOOD
DISORDERS Depression
Depressed mood, motor retardation, uneasiness & apprehension, intense dejection, self-depreciation, self-condemnation, guilt which can become delusional.
Types of Depression
Clinical or endogenous depression
Psychological or exogenous depression
Major Depression vs. Dysthymia
Major depression is an intense sadness that lasts for months.
Dysthymia is a less intense sadness with little relief for at least 2 years.
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THE MOOD
DISORDERS Suicide
30,000 people per year in the U.S.A. commit suicide.
More women attempt suicide, but more men commit it.
Men take more active means.
Stress is often involved in suicides.
Leaving home, college, career, broken romance, unemployment, financial strain are major reasons.
The person tends to be overwhelmed with hopelessness.
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THE MOOD
DISORDERS Mania
The opposite of depression.
Overtalkativeness, heightened motor activity, flight of ideas, extreme elation.
2 types of mania:
Hypomania – a mild form of mania
Acute mania – boastfulness, expansive, unrealistic, ambitious, boisterousness & violent.
The Causes of Mood Disorders
Biological cause
Genetics & biochemistry
Psychological cause
Cognitive distortions of the environment
Social cause
Interpersonal problems 23
ANXIETY DISORDERS
Anxiety is a condition in which intense feelings of fear & dread are long standing or disruptive.
5 types of anxiety disorders -Phobias -Generalized Anxiety
Disorder (GAD) -Panic Disorder (PD) -Obsessive-Compulsive
Disorder (OCD) -Posttraumatic Stress
Disorder (PTSD)
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PHOBIAS
Out-of-proportion fears associated with circumstances & objects. Most common phobias:
Social phobias
Fears associated with social situations (e.g. agoraphobia)
Object phobias
Fears associated with dogs, cats, spiders, etc.
Event phobias
Fears associated with something happening (e.g. fear of being struck by lightning, being hit by a meteor or asteroid, stepping on the cracks in a sidewalk, etc.)
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PANIC DISORDERS Recurring attacks of panic, periods of intense fear, & feelings of impending doom or death accompanied by physiological symptoms all occurring without cause.
Often seen with a phobic response.
Feelings of dizziness, problems with breathing, sweating, & trembling.
After an attack, the fear of another panic attack sets in.
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OTHER ANXIETY DISORDERS
Generalized Anxiety Disorder
Prolonged, unfocused, intense fear response.
Not attached to any object or event Obsessive-Compulsive Disorder
Persistent, intrusion of unwanted thoughts, urges, or actions that are unable to stop.
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OTHER ANXIETY DISORDERS
Posttraumatic Stress Disorder
An anxiety disorder in which a person who has experienced a traumatic or life-threatening event has symptoms such as psychic numbing, reliving of the trauma, & increased physiological arousal.
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CAUSES OF ANXIETY
DISORDERS Depends on the point
of view 1. Learned Either directly or
vicariously Locus of control seen
outside. 2. Biological Genetic predispositions. 3. Psychological Internal conflicts produce
anxiety. Follow this with extensive
use of the defense mechanisms.
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PSYCHOSOMATIC & SOMATOFORM DISORDERS
Psychosomatic Disorders Psychological factors
produce real physical disorders.
Stress is strongly indicated. Somatoform Disorders
Physical symptoms persist without any identifiable physical cause.
Conversion Disorders Hypochondriasis Body Dysmorphic
Disorder
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DISSOCIATIVE
DISORDERS Some aspect of the personality
seems to be separated from the rest.
• Dissociative Amnesia A loss of memory with no
organic cause.
Usually after a stressful event.
Usually accompanied by a Dissociative Fugue.
• Dissociative Identity Disorder Multiple Personality Disorder
Several distinct personalities in the same person.
• Depersonalization Disorder Feelings of being changed or
different in a strange way. 31
SEXUAL & GENDER-IDENTITY
DISORDERS
Sexual Dysfunction
- Erectile Disorder The inability to achieve or
maintain an erection
Physical or Psychological causes
- Female Sexual Arousal Disorder
The inability to become excited or achieve orgasm
About 1/3 have genetic construct, others are psychological
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SEXUAL DISORDERS Paraphilias
Exhibitionism Exposure of one’s genitals
to an unsuspecting stranger.
Voyeurism Observing a stranger
naked, etc. Fetishism Sexual arousal from
nonliving objects. Transvestic Fetishism Dressing in clothing of the
opposite sex.
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SEXUAL DISORDERS Sadism & Masochism
Arousal from dominating or being dominated.
Frotteurism
Touching or rubbing against a non-consenting person.
Necrophilia
Obsession with dead bodies.
Klismaphilia
Sexual excitement from enemas.
Coprophilia
Arousal through feces.
Zoophilia
Sexual activity with animals.
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GENDER-IDENTITY DISORDER
The desire to become or the insistence one is the opposite sex.
Trans-sexuals & certain transvestites
In children it is seen as boys playing with girls toys and girls playing with boys toys.
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PERSONALITY
DISORDERS Inflexible, maladaptive ways of thinking & behaving learned in early life which cause distress & conflict with others. These behaviors impair personal or social functioning & are a source of distress to the individual or to other people. Included in these disorders are: Schizotypal Personality Disorder Schizoid Personality Disorder
Paranoid Personality Disorder Dependant Personality Disorder
Avoidant Personality Disorder Narcissistic Personality Disorder
Borderline Personality Disorder Antisocial Personality Disorder
Obsessive-Compulsive Personality Disorder
Passive-Aggressive Personality Disorder
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CLUSTER 1
DISORDERS These disorders are
characterized by odd
or eccentric
behaviors or traits.
Schizoid Personality
Disorder
Characterized by the inability to form social relationships
Withdrawn with a lack of feelings toward others.
Schizotypal Personality
Disorder
Uncomfortable in interpersonal relationships, & suffering from cognitive & perceptual distortions & eccentric behavior.
May wear inappropriate, strangely out-of-date or mismatched clothes.
Paranoid Personality
Disorder
Inappropriately suspicious of others & their motives.
Guarded, secretive, devious, scheming, argumentative, & often superstitious.
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CLUSTER 2
DISORDERS Characterized by
dramatic,
emotional or
erratic behavior.
They have very
unstable
interpersonal
relationships,
self-image and
moods.
Borderline
Personality Disorder
Very unstable in self-image, mood, &
relationships.
Acts impulsively & self-destructively.
Manipulative, self-destructive impulses
when trying to control or strengthen
personal relationships.
Histrionic
Personality Disorder
Overly dramatic behavior, self-centered,
& craving attention.
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CLUSTER 2
DISORDERS Antisocial
Personality Disorder
Continually violates the rights of others,
prone to impulsive behavior, & feeling
no guilt for any harm.
Unethical, exploitative, violent, criminal
behavior.
Narcissistic
Personality Disorder
Over-inflated sense of self-importance.
Must be the center of attention, lacking
any real empathy for others.
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CLUSTER 3
DISORDERS Characterized by
anxious or fearful
behavior.
Avoidant personality
Disorder
Hypersensitive to potential rejection by others, causing social withdrawal despite a desire for social relationships.
Has social anxiety & is timid, anxious, & fearful of relationships.
Obsessive-Compulsive
Personality Disorder
Preoccupation with rules, schedules, & trivial details, & unable to express emotional warmth.
Preoccupied with orderliness & perfectionism.
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CLUSTER 3
DISORDERS Dependent Personality Disorder
The inability to make decisions or to act independently.
Fails to take responsibility for one’s own life, instead relies on other to
make their decisions.
Can’t tolerate being alone.
Has a fear of abandonment.
Passive-Aggressive Personality Disorder
Unassertive, indirect resistance to demands, as in forgetting,
procrastinating, being late, and being indifferent.
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SCHIZOPHRENIC DISORDERS
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SCHIZOPHRENIA A complex chronic disorder characterized by hallucinations, delusions, disturbances in speech, as well as other symptoms. It is divided into 5 distinct types:
Disorganized
Catatonic
Paranoid
Undifferentiated
Residual
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TYPES OF
SCHIZOPHRENIA Disorganized Type
Originally called hebephrenic
There is an absence of and shallow emotions with bizarre & silly, child-like behaviors, poorly developed delusions, regressive behavior & verbal incoherence. Catatonic Type
Unusual patterns of motor activity (e.g. rigid postures or extreme excitedness), will be either mute or extremely talkative chattering incoherently.
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TYPES OF
SCHIZOPHRENIA Paranoid Type
Preoccupied with one or more sets
of bizarre delusions (of grandeur or
persecution), often based on the
“out to get me” attitude. Is
extremely suspicious. Nothing
makes sense.
Residual Originally called simple
schizophrenia. Characterized by
withdrawal, minimal emotional
responding, absence of motivation.
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TYPES OF
SCHIZOPHRENIA
Undifferentiated Type
Has many symptoms (e.g.
delusions, hallucinations, and
incoherence) but doesn’t fit
neatly into any specific
category.
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CHILDHOOD
DISORDERS ADHD
A psychological disorder in which children are unable to concentrate their attention on any task for more than a few minutes.
Inattention, impulsiveness, hyperactive behavior
A CNS arousal problem.
Underarousal
Affects Dopamine use in the Basal Ganglia and Prefrontal Cortex
Psychostimulants are used to manage the behavior.
They increase the child’s ability to focus attention.
There are only short-term benefits.
Non-stimulant drugs are now being used. 47
CHILDHOOD
DISORDERS Autism
A condition arising in infancy, in
which the child is motivated to
avoid stimulation, including social
interaction.
They have poor social skills &
emotional responding.
They dislike changes in their
routine, perform monotonous
actions, & ignore stimuli other than
that which they are attending to.
They remain distant & withdrawn.
Dyslexia The inability to identify or write
correctly letters & words or to read
with understanding.
Generally considered a learning
disorder.
When a child is below achievement
in school learning as would be
expected for his intelligence, a
learning disorder is suspected.
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